Basic Information
| Provider Information | |||||||||
| NPI: | 1346541414 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANTHONY L. JORDAN HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JORDAN HEALTH LINK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 82 HOLLAND ST | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146052131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854235800 | ||||||||
| FaxNumber: | 5854232806 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 UPPER FALLS BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146052103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857845900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 06/28/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARBIN | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5854235800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANTHONY L. JORDAN HEALTH CORP | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 2701211R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00384969 | 05 | NY | MEDICAID | 331838 | 01 | NY | MEDICARE PART A | OTHER | 6613 | 01 | NY | BLUE CROSS OF ROCHESTER | OTHER | 16467A | 01 | NY | MEDICARE PART B | OTHER | G0187295590 | 01 | NY | BLUE CHOICE OF ROCHESTER | OTHER |